Hematoma Type Research Articles

Diffusion-weighted imaging findings predictive of postoperative recurrence of chronic subdural hematoma

ObjectivesTo identify the brain magnetic resonance imaging (MRI) findings associated with the postoperative recurrence of chronic subdural hematoma (CSDH). MethodsWe examined 1099 consecutive patients admitted to our hospital with CSDH between 2005 and 2014. Of those, 1021 who underwent surgery for CSDH and were followed-up for >3 months after surgery were included. Preoperative brain MRI findings were classified as homogeneous, laminar, separate, or trabecular, according to the nature of the hematoma. Postoperative recurrence was defined in patients who required reoperation for ipsilateral hematoma growth within three months of surgery. The clinical and radiological factors associated with postoperative recurrence were evaluated using univariate and multivariate analyses. ResultsOf the 1021 CSDH patients with CSDH who underwent surgery, 91 (8.9%) experienced postoperative recurrence. Postoperative recurrence was significantly associated with male sex (p = 0.0004) and hematoma volume (p < 0.0001). Additionally, isotype or separate types of hematoma on computed tomography (CT) (p < 0.0001) and laminar/separate types of hematoma types on MRI (p = 0.0008) were significant. Multivariate analysis revealed odds ratios of 2.50 (95% CI, 1.45–4.61; p = 0.0007) for male sex and 3.05 (95% CI, 1.95–4.87; p < 0.0001) for iso/separate hematoma types in CT. Conversely, among the patients who underwent MRI, multivariate analysis revealed odds ratios of 4.33 (95% CI, 1.20–27.92; p = 0.001) for male sex and 4.88 (95% CI, 1.90–14.18; p = 0.023) for laminar/separate hematoma types. ConclusionWhile distinguishing the nature of hematomas is challenging with brain CT examination, detailed laminar/trabecular differentiation using MRI images may predict postoperative recurrence.

Chronic Subdural Hematomas-A Retrospective Analysis of the Internal Architecture and Evaluation of Risk Factors for Recurrences After Surgical Therapy.

Background: Chronic subdural hematoma (CSDH) is increasingly common due to the aging population and widespread use of anticoagulant and antiplatelet medications. The objective of this study is to examine the internal composition of CSDH and explore potential risk factors associated with its recurrence. Methods: This retrospective study analyzed data from 189 patients who underwent surgery in our department between 2014 and 2018. Recorded data included demographics, clinical information, details of surgical interventions, computer tomography (CT) scans, neurological assessments, and follow-up data. The outcome was evaluated clinically and through CT follow-up conducted 4-12 weeks post-surgery. CT scans measured various parameters, including hematoma thickness, hyperdense regions, chronic components, and membrane presence. Results: Patients after the evacuation of CSDH were significantly more common males (66.1%, p > 0.001) had a significantly higher BMI (p < 0.001, 61.6%), arterial hypertension (p < 0.001, 68.3%), and the intake of anticoagulant therapy (p < 0.001, 58%). The recurrence rate was 18.6% after 4 weeks and 2.1% after 8-12 weeks. After uni- and multivariable analysis, the initial hemispheric type (p = 0.019, HR: 3.191; p = 0.012, HR: 3.810) and the increasing preoperative midline shift in CT (p = 0.028, HR: 1.114; p = 0.041, HR: 1.107) were found as independent predictors for recurrence. Overall, outcomes were favorable with a modified Rankin scale (mRS) of 0-2 at discharge (72%), after 4 (89.7%) and 12 (87%) weeks. Conclusion: According to our data, increasing midline shift before surgery and initial hemispheric type of hematoma were independent predictors of recurrence. Most patients achieved an excellent outcome with a low-risk profile.

Tenecteplase versus alteplase for acute stroke within 4·5 h of onset (ATTEST-2): a randomised, parallel group, open-label trial

Tenecteplase has potential benefits over alteplase, the standard agent for intravenous thrombolysis in acute ischaemic stroke, because it is administered as a single bolus and might have superior efficacy. The ATTEST-2 trial investigated whether tenecteplase was non-inferior or superior to alteplase within 4·5 h of onset. We undertook a prospective, randomised, parallel-group, open-label trial with masked endpoint evaluation in 39 UK stroke centres. Previously independent adults with acute ischaemic stroke, eligible for intravenous thrombolysis less than 4·5 h from last known well, were randomly assigned 1:1 to receive intravenous alteplase 0·9 mg/kg or tenecteplase 0·25 mg/kg, by use of a telephone-based interactive voice response system. The primary endpoint was the distribution of the day 90 modified Rankin Scale (mRS) score and was analysed using ordinal logistic regression in the modified intention-to-treat population. We tested the primary outcome for non-inferiority (odds ratio for tenecteplase vs alteplase non-inferiority limit of 0·75), and for superiority if non-inferiority was confirmed. Safety outcomes were mortality, symptomatic intracranial haemorrhage, radiological intracranial haemorrhage, and major extracranial bleeding. The trial was prospectively registered on ClinicalTrials.gov (NCT02814409). Between Jan 25, 2017, and May 30, 2023, 1858 patients were randomly assigned to a treatment group, of whom 1777 received thrombolytic treatment and were included in the modified intention-to-treat population (n=885 allocated tenecteplase and n=892 allocated alteplase). The mean age of participants was 70·4 (SD 12·9) years and median National Institutes of Health Stroke Scale was 7 (IQR 5-13) at baseline. Tenecteplase was non-inferior to alteplase for mRS score distribution at 90 days, but was not superior (odds ratio 1·07; 95% CI 0·90-1·27; p value for non-inferiority<0·0001; p=0·43 for superiority). 68 (8%) patients in the tenecteplase group compared with 75 (8%) patients in the alteplase group died, symptomatic intracerebral haemorrhage (defined by SITS-MOST criteria) occurred in 20 (2%) versus 15 (2%) patients, parenchymal haematoma type 2 occurred in 37 (4%) versus 26 (3%) patients, post-treatment intracranial bleed occurred in 94 (11%) versus 78 (9%) patients, significant extracranial haemorrhage occurred in 13 (1%) versus six (1%) patients, respectively, and angioedema occurred in six (1%) participants in both groups. Tenecteplase 0·25 mg/kg was non-inferior to 0·9 mg/kg alteplase within 4·5 h of symptom onset in acute ischaemic stroke. Easier administration of tenecteplase, especially in the context of interhospital transfers, indicates that tenecteplase should be preferred to alteplase for thrombolysis in acute ischaemic stroke. The ATTEST-2 population was large and representative of thrombolysis-eligible patients in the UK and, together with findings from other trials, provides robust evidence supporting the introduction of tenecteplase in preference to alteplase. The Stroke Association and British Heart Foundation.

A Case of Hemorrhagic Transformation with Motor and Language Impairments Treated with Korean Medicine, including Modified &lt;italic&gt;Geopoongjaeseup-tang&lt;/italic&gt; (Modified Qufeng Chushi Decoction): Case Report

Objective: The purpose of this study was to report the clinical course of complex Korean medicine to treat a patient with hemorrhagic transformation following cerebral infarction.Case presentation: A 46-year-old Korean male was hospitalized with cerebral infarction followed by hemorrhagic transformation classified as parenchymal hematoma type 2. Based on the symptoms and condition, the pattern identification of the patient was deficiency of qi and retention of fluid (Qi-xu, Tan-yin). The patient was treated with herbal medicine, acupuncture, and rehabilitation programs for 187 days. The herbal medicine consisted of modified Geopoongjaeseup-tang (modified Qufeng Chushi decoction) for the first 62 days, followed by another modified Geopoongjaeseup-tang for the next 76 days, and finally Gagamyoonjo-tang (Jiajian Runzao decoction) for the last 30 days, administered 3 times a day. After 187 days, the functional independence measure and modified Barthel index improved (from 75 to 100 and from 44 to 84, respectively), and the MMT of the right upper and lower extremities also improved (from 2+ to 3+ and from 3+ to 4, respectively). In particular, right finger flexion improved from 1 to 3- and right ankle and greater toe improved from 1+ to 4. There were no reports of adverse effects of the treatment.Conclusion: The results suggest that complex Korean medicine treatment for motor and language impairments caused by parenchymal hematoma type 2 hemorrhagic transformation may be effective in improving functions for daily living. Further studies should be conducted with a larger number of patients.

Iodine-Based Dual-Energy Computed Tomography After Mechanical Thrombectomy Predicts Secondary Neurologic Decline from Cerebral Edema After Severe Stroke.

Patients with severe stroke are at high risk of secondary neurologic decline (ND) from the development of malignant cerebral edema (MCE). However, early infarcts are hard to diagnose on conventional head computed tomography (CT). We hypothesize that high-energy (190keV) virtual monochromatic imaging (VMI) from dual-energy CT (DECT) imaging enables earlier detection of ND from MCE. Consecutive patients with severe stroke with National Institute of Health Stroke Scale (NIHSS) scores > 15 and DECT within 10h of mechanical thrombectomy from May 2020 to March 2022 were included. We excluded patients with parenchymal hematoma type 2 transformation. Retrospective analysis of clinical and novel variables included the VMI Alberta Stroke Program Early CT Score (ASPECTS), total iodine content, and VMI infarct volume. The primary outcome was secondary ND, defined using a composite outcome variable of clinical worsening (increase in NIHSS score ≥ 4 or decrease in Glasgow Coma Scale score > 2) or malignant radiographical edema (midline shift ≥ 5mm at the level of the septum pellucidum). Fisher's exact test and Wilcoxon's test were used for univariate analysis. Logistic regression was used to develop prediction models for categorical outcomes. Eighty-four patients with severe stroke with a median age of 67.5 (interquartile range [IQR] 57-78) years and an NIHSS score of 22 (IQR 18-25) were included. Twenty-nine patients had ND. The VMI ASPECTS, total iodine content, and VMI infarct volume were associated with ND. The VMI ASPECTS, VMI infarct volume, and total iodine content were predictors of ND after adjusting for age, sex, initial NIHSS score, and tissue plasminogen activator administration, with areas under the receiver operating characteristic curve (AUROC) of 0.691 (95% confidence interval [CI] 0.572-0.810), 0.877 (95% CI 0.800-0.954), and 0.845 (95% CI 0.750-0.940). By including all three predictors, the model achieved an AUROC of 0.903 (95% CI 0.84-0.97) and was cross-validated by the leave one out method, with an AUROC of 0.827. The VMI ASPECTS and VMI infarct volume from DECT are superior to the conventional CT ASPECTS and are novel predictors for secondary ND due to MCE after severe stroke. Clinical trial registration ClinicalTrials.gov identifier: NCT04189471.

Impact of intraoperative intravenous tranexamic acid on hematomas and bleeding events in gender-affirming vaginoplasty patients

One of the more common and disruptive complications of gender-affirming vaginoplasty is postoperative bleeding. The present study aimed to evaluate the impact of intraoperative intravenous tranexamic acid (IV TXA) administration on postoperative bleeding events in a large sample of gender-affirming vaginoplasty patients. Patients receiving gender-affirming vaginoplasty at the between June 2019 and July 2023 were evaluated retrospectively. IV TXA use, estimated blood loss, and bleeding complications were evaluated. Postoperative complications included minor hematomas, defined as hematomas requiring conservative treatment; major hematomas, defined as hematomas requiring intervention such as return to the operating room and readmission; major bleeding, defined as continuous bleeding from the surgical site requiring intervention; and readmission and reoperation related to bleeding. Statistical significance was set at p<0.05. In total, 628 patients were included in the study, 271 did not receive IV TXA and 357 received IV TXA. Surgeon preference dictated IV TXA use. Significantly fewer patients in the IV TXA group had a hematoma event (18% vs. 2%, p<0.001), a minor hematoma (16% vs. 3%, p<0.001), postoperative major bleeding (4% vs. 2%, p=0.008), and readmission for bleeding (6% vs. 1%, p=0.018). On logistic regression analysis, IV TXA use was associated with a decreased odds of developing any type of hematoma (OR 0.140, 95% CI 0.071-0.277, p<0.001), a minor hematoma (OR 0.126, 95% CI 0.059-0.270, p<0.001), and postoperative bleeding (OR 0.348, 0.153-0.794, p=0.012). The use of IV TXA reduces certain bleeding events in gender-affirming vaginoplasty patients, complications that can cause distress in the postoperative period.

Factors influencing hematoma expansion in delayed brain CT scans of patients with traumatic Epidural Hematoma.

Epidural hematoma (EDH) is a type of intracranial hematoma commonly observed in trauma patients. This research aims to evaluate the factors contributing to the expansion of traumatic epidural hematoma (EDH). This retrospective cohort study examined traumatic patients with EDH admitted to Taleqani Hospital, a prominent Western Trauma Center in Iran, from 2018 to 2023. Patients underwent an initial CT scan, and non-surgical patients received a delayed CT scan approximately 5 hours after the initial scan. Data analysis was performed using SPSS version 25 software. The study included 274 brain trauma patients with epidural hematoma. Among these patients, 142 (51.8%) did not undergo surgery, and 121 (85.2%) of the non-surgical patients were male. Motor vehicle accidents (MVAs) were the primary cause of EDH in 127 (46.4%) patients. The mean (±standard deviation) initial hematoma size was 8.86 (±9.71), and the mean (±standard deviation) delayed CT scan size was 8.12 (±8.10). In crude linear regression Two variables, namely Hematoma volume in the initial CT scan (P less than 0.001) and Mixed Density (P=0.007), were found to significantly impact the increase in hematoma size in delayed CT scans of non-surgical patients. But in the adjusted linear regression model, only the Hematoma volume in primary CT scan, was significant (P less 0.001). The R Square values were 0.72. The identification of key variables influencing hematoma volume in delayed CT scans has the potential to guide more effective interventions, thereby improving patient outcomes and reducing trauma-related mortality.

Thrombectomy for Stroke With Large Infarct on Noncontrast CT

Recent large infarct thrombectomy trials used heterogeneous imaging modalities and time windows for patient selection. Noncontrast computed tomographic (CT) scan is the most common stroke imaging approach. It remains uncertain whether thrombectomy is effective for patients with large infarcts identified using noncontrast CT alone within 24 hours of stroke onset. To evaluate the effect of thrombectomy in patients with a large infarct on a noncontrast CT scan within 24 hours of onset. Open-label, blinded-end point, bayesian-adaptive randomized trial with interim analyses for early stopping (futility or success) or population enrichment, which was conducted at 47 US academic and community-based stroke thrombectomy centers. Three hundred patients presenting within 24 hours with anterior-circulation, large-vessel occlusion and large infarct on noncontrast CT scan, with Alberta Stroke Program Early CT Scores of 2 to 5, were randomized to undergo thrombectomy or usual care. Enrollment occurred July 16, 2019 to October 17, 2022; final follow-up, January 25, 2023. The intervention patients (n = 152) underwent endovascular treatment using standard thrombectomy devices and usual medical care. Control patients (n = 148) underwent usual medical care alone. The primary efficacy end point was improvement in 90-day functional outcome measured using mean utility-weighted modified Rankin Scale (UW-mRS) scores (range, 0 [death or severe disability] to 10 [no symptoms]; minimum clinically important difference, 0.3). A bayesian model determined the posterior probability that the intervention would be superior to usual care; statistical significance was a 1-sided posterior probability of .975 or more. The primary adverse event end point was 90-day mortality; secondary adverse event end points included symptomatic intracranial hemorrhage and radiographic intracranial hemorrhage. The trial enrolled 300 patients (152 intervention, 148 control; 138 females [46%]; median age, 67 years), without early stopping or enrichment; 297 patients completed the 90-day follow-up. The mean (SD) 90-day UW-mRS score was 2.93 (3.39) for the intervention group vs 2.27 (2.98) for the control group with an adjusted difference of 0.63 (95% credible interval [CrI], -0.09 to 1.34; posterior probability for superiority of thrombectomy, .96). The 90-day mortality was similar between groups: 35.3% (53 of 150) for the intervention group vs 33.3% (49 of 147) for the control group. Six of 151 patients (4.0%) in the intervention group and 2 of 149 (1.3%) in the control group experienced 24-hour symptomatic intracranial hemorrhage. Fourteen patients of 148 (9.5%) in the intervention group vs 4 of 146 (2.7%) in the control group experienced parenchymal hematoma type 1 hemorrhages; 14 (9.5%) in the intervention group vs 5 (3.4%) in the control group experienced parenchymal hematoma type 2 hemorrhages; and 24 (16.2%) in the intervention group vs 9 (6.2%) in the control group experienced subarachnoid hemorrhages. Among patients with a large infarct on noncontrast CT within 24 hours, thrombectomy did not demonstrate improvement in functional outcomes. But the width of the credible interval around the effect estimate includes the possibility of both no important effect and a clinically relevant benefit, so the potential role of thrombectomy with this imaging approach and time window will likely require additional study. ClinicalTrials.gov Identifier: NCT03805308.

Depressed "ping pong" skull fractures in the newborns: A cohort study.

A ping pong fracture is a rare depressed skull fracture (DSF) observed in infants. It occurs due to the inward buckling of the calvarium, creating a cup-like shape. Trauma during childbirth, particularly from instrumental delivery or the application of pressure by physicians or midwives during challenging deliveries, is the primary cause. This study aimed to investigate the epidemiologic characteristics associated with DSF in newborns and to identify the main factors related to its incidence and the type of hematoma involved. This is a retrospective case-control analysis of all newborns delivered with DSF at King Abdulla University Hospital in Jordan between January 2008 and December 2020. The medical records were reviewed, and clinical data were collected and analyzed. Out of 42,955 live births delivered at King Abdulla University Hospital, 13 cases of DSF were observed, giving an incidence of 3.0 in 10,000 live births. All cases were delivered at full term. Of the 13 cases, nine cases were associated with the use of instrumental delivery. Seven of those nine cases were delivered vaginally, while the other two cases required cesarean section following unsuccessful instrumental delivery. Four cases were spontaneous, with no history of trauma or instrument use, and delivered by cesarean section. Only 3 of the 13 cases required neurosurgical elevation of DSF. The outcome was excellent in all cases, both cosmetically and neurologically. Ping-pong skull fractures are seen in newborns infrequently in the Jordanian population, with an incidence of 0.03%. Most of the cases have resulted from difficult deliveries though spontaneous fractures can be encountered rarely. The treatment is usually conservative with spontaneous resolution. The overall prognosis is excellent both neurologically and cosmically.

Intracranial hematoma segmentation on head CT based on multiscale convolutional neural network and transformer

AbstractIntracranial hematoma, a severe brain injury caused by trauma or cerebrovascular disease, can result in blood accumulation and compression of brain tissue. Untreated cases can cause headaches, impaired consciousness, and even brain tissue damage or death. Therefore, early and accurate diagnosis is crucial. Traditional segmentation methods require physicians with extensive clinical experience and expertise to manually mark out the hematoma region, but for hematoma cases with irregular shapes and uneven grey levels, this process is cumbersome, and the segmentation results are not good. Existing deep learning‐based methods are more likely to perform binary segmentation, considering all hematomas as a class and segmenting them, but this segmentation cannot capture more detailed information and lacks the analysis of different types of hematomas. To address these problems, an ICH segmentation network combining CNN and Transformer Encoder is proposed for accurate segmentation of different types of hematomas. The network incorporated edge information and long‐range context into the segmentation process. Experimental results using the CQ500 dataset demonstrate comparable performance to existing methods, with mIoU (0.8705), TPR (0.9273), mAP (0.9300), and DSC (0.9286) as the best metrics achieved by this paper's method.

Radial Artery Compression Comparison for Hemostasis with and without Steri-Strips Reinforcement: RACC Randomized Trial

Objectives: This study assessed the efficacy of using steri-strips in conjunction with conventional pneumatic trans-radial (TR) bands for achieving radial artery hemostasis after diagnostic coronary angiography (CA). With varying methods aimed at reducing compression duration post-CA via trans-radial access (TRA), our aim was to evaluate time dynamics. Methodology: We randomly assigned 209 patients in a 1:1 ratio to receive either the TR band with steri-strips (treatment) or conventional TR band alone (control) post-diagnostic CA, and followed them for one month. The primary endpoint was time to achieve adequate hemostasis, defined by the total TR band application duration. Secondary endpoints included radial artery occlusion (RAO) and major bleeding. The treatment group comprised 106 patients with steri-strips alongside the TR band, while the control group had 103 patients with the TR band alone. Median TR band application duration was 60 [IQR: 60-60] min in the treatment group and 250 [IQR: 240-360] min in the control group; p≤0.001. Results: The incidence of site bleed requiring TR band re-application was 9.4% vs. 4.9%, p=0.364, and hematoma (type I only) was 7.5% vs. 9.7%, p=0.578 in the treatment and control groups, respectively. Radial artery palpability after 24 hours was 95.3% vs. 85.4%; p=0.016, and at one month it was 96.2% vs. 88.3%; p=0.032 in the treatment and control arms, respectively. Conclusion: Steri-strips significantly reduce TR band compression duration and improve radial artery patency post-diagnostic angiography without causing hematoma or major bleeding complications.

ПРИОБРЕТЕННАЯ ГЕМОФИЛИЯ А В РЕАЛИЯХ СОВРЕМЕННОЙ МЕДИЦИНЫ: ОПЫТ КЛИНИЧЕСКОЙ ПРАКТИКИ

Abstract. Introduction. Acquired hemophilia A is a rare form of severe coagulopathy with an autoimmune mechanism of development. It occurs due to the formation of circulating inhibitory factor VIII (FVIII) antibodies, which leads to impaired activation of factor X and the occurrence of spontaneous bleeding in patients without previous hemostasis system pathology. In about a half of the cases, FVIII autoantibodies appear in patients without any comorbidities. It should be noted that the average age of patients was 74 years at the time of diagnosis. However, the occurrence of the disease in young women is rare and may be associated with pregnancy and childbirth. Given the rarity of this disease, the management of these patients is a challenging clinical problem. Aim. To describe a clinical case of diagnosis and treatment of a patient with the inhibitor form of acquired hemophilia A (AHA). Materials and Methods. A 38–year–old female patient had acute hemorrhagic syndrome of the hematoma type, manifested by large hematomas in different areas of the body. During the patient’s stay in the hospital, standard lab tests were made, the test results were evaluated over time, and instrumental diagnostics was performed. Results and Discussion. The typical hematoma type of bleeding detected during diagnosing, prolongation of coagulation parameters, presence of factor VIII inhibitor (605 BU), and a decrease in factor VIII level down to 0.5%) verified the AHA diagnosis. Methods of substitution, immunosuppressive therapy, and monoclonal antibodies were successfully used to treat AHA in this patient. The patient is followed up by a hematologist at the place of residence. Hematomas did not recur. Conclusions. This clinical observation demonstrates the peculiarities of the course, diagnostic algorithm, and management of patients with AHA without any concomitant pathology, with a history of only prolonged postpartum uterine bleeding, and with no autoimmune or malignant diseases.

Two Cases of Postpartum HELLP Syndrome: A Rare Presentation of Preeclampsia-Associated Liver Disease and Hepatocellular Dysfunction

Background: HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is a severe and sometimes fatal pregnancy condition characterized by hemolysis, increased liver enzymes, and low platelet count. While most cases occur before delivery, approximately 25% of cases manifest within 48 hours after delivery. One rare but life-threatening complication of HELLP syndrome is intraparenchymal liver hematoma. Case: In this report, we present two postpartum HELLP syndrome patients with diverse clinical manifestations. Case 1 involves a 30-year-old woman who presented with a significant subcapsular liver hematoma as a complication of postpartum preeclampsia-associated liver illness. Following conservative treatment, she improved significantly, and no surgical intervention was required. This type of subcapsular hematoma occurs in less than 2% of pregnancies complicated by HELLP. Case 2 describes an unusual HELLP presentation in a 38-year-old woman who was diagnosed with postpartum HELLP syndrome with acute liver injury and hepatic hemorrhage. Conclusion: These unique presentations underscore the significance of early detection and prompt treatment of postpartum HELLP syndrome, as it can significantly reduce risks to the mother’s health and improve overall outcomes.

Hypoperfusion index ratio and pretreatment with intravenous thrombolysis are independent predictors of good functional outcome in acute ischemic stroke patients with large vessel occlusion treated with acute reperfusion therapies.

We aimed to investigate the performance of several neuroimaging markers provided by perfusion imaging of Acute Ischemic Stroke (AIS) patients with large vessel occlusion (LVO) in order to predict clinical outcomes following reperfusion treatments. We prospectively evaluated consecutive AIS patients with LVO who were treated with reperfusion therapies, during a six-year period. In order to compare patients with good (mRS scores 0-2) and poor (mRS scores 3-6) functional outcomes, data regarding clinical characteristics, the Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) based on unenhanced computed tomography (CT), CT angiography collateral status and perfusion parameters including ischemic core, hypoperfusion volume, mismatch volume between core and penumbra, Tmax > 10s volume, CBV index and the Hypoperfusion Index Ratio (HIR) were assessed. A total of 84 acute stroke patients with LVO who met all the inclusion criteria were enrolled. In multivariable logistic regression models increasing age (odds ratio [OR]: 0.93; 95%CI: 0.88-0.96, p = 0.001), lower admission National Institute of Health Stroke Scale (NIHSS)-score (OR: 0.88; 95%CI: 0.80-0.95, p = 0.004), pretreatment with intravenous thrombolysis (OR: 3.83; 95%CI: 1.29-12.49, p = 0.019) and HIR (OR:0.36; 95%CI: 0.10-0.95, p = 0.042) were independent predictors of good functional outcome at 3months. The initial univariable associations between HIR and higher likelihood for symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2) were attenuated in multivariable analyses failing to reach statistical significance. Our pilot observational study of unselected AIS patients with LVO treated with reperfusion therapies demonstrated that pre-treatment low HIR in perfusion imaging and IVT were associated with better functional outcomes.

Quantitative Assessment of Brain Expansion After Evacuation of Chronic Subdural Hematoma as a Predictor of Recurrence

A lack of brain expansion is considered a risk factor for recurrence after evacuation of a chronic subdural hematoma (CSDH). To the best of our knowledge, no studies have reported on objective measurement of brain expansion after evacuation of a CSDH. We performed a retrospective analysis of prospectively collected data of patients undergoing 2 burr hole evacuation of a CSDH. We measured the depth of the brain surface from the frontal burr hole dural opening after hematoma evacuation using a specially devised measuring tool. Other predictors analyzed for recurrence of hematoma were age, gender, a history of hypertension, the use of anticoagulant and/or antiplatelet agents, Glasgow coma scale score at presentation, unilateral or bilateral hematoma, computed tomography appearance, and hematoma thickness. Among 88 patients who underwent hematoma evacuation, 3 (3.4%) underwent surgery for recurrence. The significant factors associated with recurrence were the presence of bilateral hematoma (P= 0.001), hematoma width >2.3 cm (P= 0.04), gradation type of hematoma on the computed tomography scan (P= 0.03), and the depth of the brain after hematoma evacuation (P= 0.02). The brain expanded less in those with recurrence, with a mean depth of the brain of 18 ± 6 mm versus 7.27 ± 7.8 mm in those without recurrence. Evacuation of a CSDH through 2 burr holes, along with copious irrigation and bed rest for 3 days, resulted in a very low recurrence rate without the use of a drain. A lack of brain expansion might be a predictor of recurrence. To the best of our knowledge, this is the first study to quantitatively measure the depth of the brain at surgery in patients undergoing surgery for CSDH.

Hemorrhagic Transformation in Noncardioembolic Acute Ischemic Stroke: MRI Analysis From PACIFIC-STROKE.

In the phase 2 PACIFIC-STROKE trial (Proper Dosing and Safety of the Oral FXIa Inhibitor BAY 2433334 in Patients Following Acute Noncardioembolic Stroke), asundexian, an oral factor XIa inhibitor, did not increase the risk of hemorrhagic transformation (HT). In this secondary analysis, we aimed to investigate the frequency, types, and risk factors of HT on brain magnetic resonance imaging (MRI). This was a secondary analysis of the PACIFIC-STROKE trial. Patients with mild-to-moderate acute noncardioembolic ischemic stroke were randomly assigned to asundexian or placebo plus guideline-based antiplatelet therapy. Brain MRIs were required at baseline (≤120 hours after stroke onset) and at 26 weeks or end-of-study. HT was defined using the Heidelberg classification and classified as early HT (identified on baseline MRI) or late HT (new HT by 26 weeks) based on iron-sensitive sequences. Multivariable logistic regression models were used to test factors that are associated with early HT and late HT, respectively. Of 1745 patients with adequate baseline brain MRI (mean age, 67 years; mean National Institutes of Health Stroke Scale score, 2.8), early HT at baseline was detected in 497 (28.4%). Most were hemorrhagic infarctions (hemorrhagic infarction type 1: 15.2%; HI2: 12.7%) while a few were parenchymal hematomas (parenchymal hematoma type 1: 0.4%; parenchymal hematoma type 2: 0.2%). Early HT was more frequent with longer symptom onset-to-MRI interval. Male sex, diabetes, higher National Institutes of Health Stroke Scale large (>15 mm) infarct size, cortical involvement by infarct, higher number of acute infarcts, presence of chronic brain infarct, cerebral microbleed, and chronic cortical superficial siderosis were independently associated with early HT in the multivariable logistic regression model. Of 1507 with follow-up MRI, HT was seen in 642 (42.6%) overall, including 361 patients (23.9%) with late HT (new HT: 306; increased grade of baseline HT: 55). Higher National Institutes of Health Stroke Scale, large infarct size, cortical involvement of infarct, and higher number of acute infarcts predicted late HT. About 28% of patients with noncardioembolic stroke had early HT, and 24% had late HT detectable by MRI. Given the high frequency of HT on MRI, more research is needed on how it influences treatment decisions and outcomes.

Factors associated with success of conservative therapy in chronic subdural hematoma: a single-center retrospective analysis

IntroductionConservative therapy is a viable option for patients with chronic subdural hematoma (cSDH) who express no, or only mild symptoms. It is not clear which factors are associated with success of conservative therapy. This study aims to determine conservative therapy's success rate and to identify features possibly associated with success.MethodsA monocenter retrospective cohort study, including cSDH patients treated conservatively (wait-and-watch) from 2012 to 2022, was performed. The primary outcome was success of conservative therapy, defined as ‘no crossover to surgery’ during the follow-up period. Secondary outcomes were (1) factors associated with success, analyzed with univariate and multivariable logistic regression analyses, (2) 30-day mortality (3) time to crossover and (4) reasons for crossover.ResultsWe included 159 patients. Conservative therapy was successful in 96 (60%) patients. Hematoma volume (OR 0.79, 95% CI 0.69–0.92) and hypodense hematoma type (OR 3.57, 95% 1.38–9.23) were associated with success. Thirty-day mortality rate was 5% and the median duration between diagnosis and surgery was 19 days (IQR 8–39). Clinical deterioration was the most frequent reason for crossover (in 61/63 patients, 97%) and was accompanied by radiological hematoma progression in 42 patients (67%).ConclusionIn this selected group of patients, conservative therapy was successful in 60%. Smaller hematoma volume and hypodense hematoma type were associated with success. As time until crossover was approximately three weeks, deploying conservative therapy as primary treatment seems safe and could be rewarding as surgical complications can be avoided. Improvement in patient selection in future cohorts remains warranted.

Clinical relevance of intracranial hemorrhage after thrombectomy versus medical management for large core infarct: a secondary analysis of the SELECT2 randomized trial

BackgroundThe incidence of intracerebral hemorrhage (ICH) and its effect on the outcomes after endovascular thrombectomy (EVT) for patients with large core infarcts have not been well-characterized.MethodsSELECT2 trial follow-up imaging was...

Cardiac Implantable Electronic Device (CIED) Infections, Associated Risk Factors and Optimization in Reducing CIED Infections; An Experience of Tertiary Care Hospital of Pakistan

Objective: To determine the frequency of infections in cardiac implantable Electronic device patients, identify risk factors, and look for optimization in reducing Cardiac Implantable Electronic Device infections, with a resultant decrease in mortality and morbidity, decrease in hospital stay, and total expenditure. Study Design: Cross-sectional study. Place and Duration of Study: Electrophysiology Department of National Institute of Cardiovascular Diseases, Karachi Pakistan, from Jul 2019 to Jun 2020. Methodology: The study was conducted on the patients with cardiac implantable devices. Adult patients of either genderwith cardiac implantable Electronic device and infection were included. Epicardial leads and surgical site infections within six weeks were excluded. Results: One thousand and forty-six (1046) patients were enrolled in the study. There were 596(57%) male patients. 385(36.8%) patients were implanted with single chamber pacemakers, 390(37.3%) with dual chamber pacemakers, 146(14%) single chamber ICD (implantable cardiac defibrillator), 67(6.4%) dual-chamber cardiac implantable Electronic device, 46(4.4%) CRT-D, 12(1.1%) TPM, 134(12.8%) Re-do, 114(10.9%), 114(10.9%) generator change, 20(1.9%) leads revision, 26(2.5%) patients had extraction. The rate of CIED infection was 34(2.1%). The association of the study parameters with infection rate revealed that type of device (p=0.002), extraction, suture type, and post-procedure hematoma (p&lt;0.001) had a statistically significant relationship with infection rate.Conclusion: The Cardiac Implantable Electronic Device infection rate was 2.1%. Hypertension and diabetes were common risk factors, and left ventricular dysfunction was common in high-energy devices with multiple leads and repeated procedures.

Magnetic Resonance Imaging-Guided Intravenous Thrombolysis in Cardioembolic Stroke Patients With Unknown Time of Onset - Subanalysis of the THAWS Randomized Control Trial.

We investigated the clinical effect of intravenous thrombolysis using a magnetic resonance imaging (MRI)-guided approach in cardioembolic stroke (CE) patients with unknown time of onset. This subanalysis of the THAWS trial assessed the efficacy and safety of alteplase 0.6 mg/kg in CE patients with unknown time of onset and showing diffusion-weighted imaging-fluid-attenuated inversion recovery mismatch. Patients were classified as CE and non-CE using the SSS-TOAST classification system during the acute period. The efficacy outcome was a modified Rankin Scale score of 0-1 at 90 days. In all, 126 patients from the THAWS trial were included in this study, of whom 45 (35.7%) were diagnosed with CE. In the CE group, a favorable outcome was numerically more frequent in the alteplase than control group (52% vs. 35%; adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 0.50-9.99). However, in the non-CE group, favorable outcomes were comparable between the alteplase and control groups (44% vs. 55%, respectively; aOR 0.39; 95% CI 0.12-1.21). Treatment-by-cohort interaction for a favorable outcome was modestly significant between the CE and non-CE groups (P=0.069). In the CE group, no patients experienced symptomatic intracranial hemorrhage (ICH) or parenchymal hematoma Type II following thrombolysis. When an MRI-guided approach is used, CE patients with unknown time of onset appear to be suitable candidates for thrombolysis.